Tibialis anterior tendon entrapment after ankle tightrope insertion for acute syndesmosis injury

Biomechanical comparison of suture-button, bioabsorbable screw, and metal screw for ankle syndesmotic repair: A meta-analysis

BACKGROUND

To compare biomechanically metal screw fixation to suture-button or bioabsorbable screw fixation for ankle syndesmotic injuries.

METHODS

A literature search of the comparison studies in Pubmed and Google Scholar was conducted. The biomechanical outcomes of interest were syndesmotic stability in the coronal, sagittal, and axial planes as well as torque and rotation at failure.

RESULTS

A total of 11 cadaveric studies were included. In the suture-button group, coronal displacement (MD 1.72mm, p = 0.02) and sagittal displacement (MD 2.65mm, p = 0.0003) were increased relative to the metal screw group. In contrast, no difference was found with axial rotation (MD 0.35 degrees, p = 0.57). Bioabsorbable screws exhibited equivalent failure torque (MD -3.04Nm, p = 0.53) and rotation at failure (MD 3.77 degrees, p = 0.48) in comparison to metal screws.

CONCLUSIONS

Suture-button provide less rigidity when compared to metal screw fixation. They afford flexible syndesmotic micromotion which may more closely resemble a physiological state and be helpful for ligament healing. Bioabsorbable screws demonstrate similar mechanical strength properties to metal screws.

Comparison of tendon suture fixation and cortical screw fixation for treatment of distal tibiofibular syndesmosis injury: A case-control study

This study aimed to investigate the effectiveness of tendon suture fixation versus cortical screw fixation for the treatment of distal tibiofibular syndesmosis injury.This study recruited 42 patients with Danis-Weber type B, C1 and C2 fractures concomitant with lower tibiofibular syndesmosis injury, who were randomly assigned to 2 groups according to treatment with cortical screw fixation (n = 21) and tendon suture fixation (n = 21). Operation time, intraoperative blood loss, time to full weight-bearing activity, medical cost, ankle function, and ankle pain were compared between the 2 groups.The operation time was significantly less with cortical screw fixation (57.1 ± 5.3 min) than with tendon suture fixation (63.3 ± 6.3 min; p = 0.01), but there was no significant difference in intraoperative blood loss. The time until full weight-bearing was possible was significantly longer after cortical screw fixation (10.9 ± 2.7 weeks) than after tendon suture fixation (7.1 ± 1.9 weeks; P < .001). The medical cost was much greater for cortical screw fixation (1861.6 ± 187.3 USD) than for tendon suture fixation (1209.6 ± 97.6 USD; P < .01). The rate of excellent and good ankle function at 3 months after surgery was significantly higher with tendon suture fixation (71.4%) than with cortical screw fixation (33.3%; P = .03).Tendon suture fixation is associated with quicker recovery of ankle function, shorter time to full weight-bearing, and lower medical cost to the patient compared with screw fixation. Our findings suggest that tendon suture fixation is an effective method for the treatment of tibiofibular syndesmosis injury.

Anatomic Ligament Repairs of Syndesmotic Injuries

Poor clinical results are seen with syndesmotic injuries in the setting of ankle sprains and ankle fractures. The goal of syndesmosis repair is to restore the normal anatomic relationship of the distal tibiofibular joint and prevent ankle arthritis. Indications for surgical intervention for isolated syndesmotic injuries include frank syndesmosis diastasis, medial clear space widening on plain radiographs, significant radiographic syndesmosis diastasis during stress examination, or subtle syndesmotic diastasis detected by arthroscopic evaluation. Complications after syndesmosis repair include symptomatic hardware, malreduction, and arthritis. Anatomic reduction of the syndesmosis leads to better outcomes following surgery.

Medial Structure Injury During Suture Button Insertion Using the Center-Center Technique for Syndesmotic Stabilization

BACKGROUND

The center-center technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of flexible fixation with a suture button is becoming an established means of syndesmosis stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button using the center-center technique for ankle syndesmosis repair at 3 insertion intervals.

METHODS

Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the center-center technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was subsequently passed through each drill-hole interval. A single observer used a digital caliper to measure the distance from each suture button aperture with respect to the tibialis anterior tendon, tibialis posterior tendon, and greater saphenous vein and nerve.

RESULTS

A total of 30 interval measurements (10 cadavers with 3 suture button segments each) were used for data analysis. Direct impingement on the greater saphenous vein was seen in 11 of 30 (36.6%) interval measurements. Six of the 11 (54.5%) observed saphenous structure impingement events occurred at the 10-mm drill hole.

CONCLUSION

The results of the present study suggest that the use of the center-center technique for syndesmosis repair with suture button fixation risks preventable injury to the greater saphenous neurovasculature.

CLINICAL RELEVANCE

To understand the medial ankle anatomy, as it pertains to insertion of flexible syndesmotic fixation in a cadaveric model, to aid in prevention of clinical iatrogenic injury.

Slippage of Tightrope Button in Syndesmotic Fixation of Weber C Malleolar Fractures: A Case Series

BACKGROUND

Tightrope fixation is an emerging technique for syndesmotic fixation with promising results. However, our case series highlights the slippage of Tightrope buttons as a complication of suture button syndesmotic fixation of Weber C malleolar fractures using limited contact dynamic compression (LCDCP) plates.

METHODS

We report a series of cases from our database in which slippage of the Tightrope button through the LCDCP holes in Weber C malleolar fractures was noted. We measured the medial clear space (MCS), tibiofibular clear space (TFCS), and distal tibiofibular overlap (DTFO) and computed the largest change in these measurements from the first postoperative follow-up radiographs. Patient records were reviewed for persistent symptoms that could be attributed to the loss of syndesmotic fixation and stability.

RESULTS

Follow-up radiographs of 3 patients showed a slippage of the Tightrope button through the LCDCP holes. Two of the patients reported persistent ankle pain and swelling with prolonged activity. The mean increases in MCS and TFCS among these patients were 0.7 (±0.081) mm and 1.5 (±0.798) mm, respectively. The mean decrease in DTFO was 2.2 (±0.864) mm. We next highlight 3 patients with Weber C malleolar fractures who underwent suture button syndesmotic fixation using double-stacked one-third tubular plates instead of the LCDCP.

CONCLUSION

This case series reported Tightrope button slippage as an early complication of syndesmotic fixation of Weber C malleolar fractures. We propose the use of double-stacked one-third tubular plates instead of the LCDCP to avoid this complication.

LEVEL OF EVIDENCE

Level V, expert opinion.

Management of acute injuries of the tibiofibular syndesmosis

The syndesmosis is important for ankle stability and load transmission and is commonly injured in association with ankle sprains and fractures. Syndesmotic disruption is associated with between 5 and 10% of ankle sprains and 11-20% of operative ankle fractures. Failure to recognize and appropriately treat syndesmotic disruption can portend poor functional outcomes for patients; therefore, early recognition and appropriate treatment are critical. Syndesmotic injuries are difficult to diagnose, and even when identified and treated, a slightly malreduced syndesmosis can lead to joint destruction and poor functional outcomes. This review will discuss the relevant anatomy, biomechanics, mechanism of injury, clinical evaluation, and treatment of acute injuries to the ankle syndesmosis.

The use of TightRope fixation for ankle syndesmosis injuries: our experience

PURPOSE

Ten percentage of all ankle fractures sustain an associated syndesmotic injury. TightRope is a relatively new technique for syndesmosis fixation, characterized by a non-absorbable FibreWire held tight between two cortical metal buttons. The purpose of this study was to evaluate the results obtained with the use of this device.

METHODS

From January 2011 to December 2015, 54 patients with ankle diastases were treated. Eighteen patients were excluded from the study. Fractures of the fibula or tibia requiring fixation were internally fixed using standard AO techniques. Preoperative and the most recent postoperative ankle radiographs were reassessed for measurements of the tibiofibular clear space (TFCS), medial clear space (MCS) and tibiofibular overlap (TFO). Clinical outcomes were assessed at the time of follow-up using the American Orthopaedic Foot and Ankle Society (AOFAS) score, a self-administered Foot and Ankle Disability Index (FADI) score and patients satisfaction.

RESULTS

The mean follow-up was 28, 64 months. Mean values for MCS, TFCS and TFO were 1.51-1.53 and 0.25 cm, respectively. The mean AOFAS score was 93.11, and the mean FADI score was 130.11. Twenty-nine (80.6 %) patients reported their outcome as excellent or very good.

CONCLUSIONS

TightRope technique can achieve flexible fixation of the syndesmosis and permit full range of motion of the tibiofibular joint. Patients can start rehabilitation exercise at an early stage after operation. The results of this study indicate that TightRope fixation is a valid option for syndesmotic injuries.

A systematic review on dynamic versus static distal tibiofibular fixation

BLACKGROUND

In the last couple of years dynamic fixation for syndesmosis injuries, using a suture-button technique, raised more interest due to its advantages over the static fixation. In the current systematic review suture-button fixation is compared to the traditionally applied static fixation in unstable ankle fractures accompanied with distal tibiofibular syndesmosis injury, including the functional outcome, post-operative complications, reoperation rate, recurrent diastasis and financial aspects.

METHODS

A computerized literature search using PubMed/MEDLINE and EMBASE was conducted in search of suitable articles between January 2006 and February 2016. A total of 4 suture-button studies, 5 suture-button vs. static fixation studies and 1 study discussing the financial aspects were identified.

RESULTS

The AOFAS of 104 patients treated with the suture-button device was 91.08 points with an average study-follow up of 24.85 months. The AOFAS of 106 patients treated with a static fixation device was 87.95 with an average follow-up of 24.78 months. Removal of the suture-button device was reported in 10.5% of 229 patients and removal of the screws in 38.5%.

CONCLUSIONS

Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. They can accurately stabilize the ruptured syndesmosis without device breakage or loss of reduction.

LEVEL OF EVIDENCE

1A economic/decision.

Assessment of Anatomic Risk During Syndesmotic Stabilization With the Suture Button Technique

The suture button technique represents an accepted method of fixation for acute or chronic injury to the tibiofibular syndesmosis. The objective of the present investigation was to assess the anatomic risk to the superficial medial neurovascular structure with insertion of a syndesmotic suture button and to measure the distance of the button to the greater saphenous vein during a standardized insertion. A syndesmotic suture button was inserted with a standardized technique in 20 fresh frozen cadaveric limbs. Of 20 suture buttons, 14 (70.0%) were inserted posterior to the greater saphenous vein, 2 (10.0%) were inserted anterior to the greater saphenous vein, and 4 (20.0%) were inserted directly onto the greater saphenous vein. A total of 11 suture buttons (55.0%) were inserted with some entrapment of a medial neurovascular structure. The absolute mean ± standard deviation distance of the suture button to the greater saphenous vein was 4.88 ± 4.44 mm. The results of the present investigation have indicated that a risk of entrapment of superficial medial neurovascular structures exists with insertion of a suture button for syndesmotic fixation and that a medial incision should be used to ensure that structures are not entrapped.